• Non-formulary drugs approved for coverage will be covered at the non-preferred brand level.

A fast DER or exception request can be made verbally by calling 1-888-547-5252 (TTY/TDD users call 1-888-816-5252) Monday - Sunday from 7:00 a.m. - 2:00 a.m. Eastern.  To make a coverage determination request or an exception request, see instructions and forms below.

• Member Drug Evaluation Review Form (DER)/Member Coverage Determination Form
• Provider/Physician Drug Evaluation Review DER Form
• Provider/Physician Injectible/Infusion Order Form/DER Form

To obtain more information on the aggregate number of WellCare’s grievances, appeals, and exceptions please contact WellCare customer service at 1-888-547-5252 (TTY/TDD users call: 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern.

Please click here to access the Evidence of Coverage, Section 6 for more detailed information on coverage determination, exception requests and appeals requests.
 

Appeals (Redetermination)

An appeal is the type of complaint you or your appointed representative make when you or your appointed representative want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. In order to file an appeal, you must first go through the DER process. An appeal must be filed within 60 calendar days of the denied DER. There are two types of appeals—fast and standard. Members can request a fast review of an appeal. The request for a fast appeal must meet the criteria that the standard process time frame would jeopardize the member’s health status. These fast reviews will be completed within 72 hours. Standard appeal requests will be reviewed within seven calendar days. Members can make a fast appeal request by calling 1-888-547-5252 or faxing their request to 1-866-388-1766. To make a standard appeal request or appoint a representative, see instructions and forms below.

• Member Appeal (Redetermination) form
• Provider/Physician Appeal form
• Appointment of Representative form

Second Level Appeal (Reconsideration)

If we deny any part of your appeal, you have the right to ask for an independent organization review of your case. This independent review organization contracts with the Federal government and is not part of our Plan. You must make a request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal.

There are two types of reconsiderations, fast and standard. The rules about asking for a fast reconsideration are the same as the rules about asking for a fast redetermination, except your prescribing doctor cannot file the request for you—only you or your appointed representative may file the reconsideration request. For a standard request, the independent review organization has up to seven calendar days from the date it gets your request to give you a decision. For a fast decision about a Part D drug that you have not received, the independent review organization has up to 72 hours from the time it gets the request to give you a decision. You must send your written request to the Independent Review Organization whose name and address is included in the redetermination notice and on the form below.

• Member IRE Reconsideration form

Grievances

A grievance is the type of complaint you make if you have any other type of problem with WellCare or one of our network pharmacies. If you have a grievance, we encourage you to call customer service. We will try to resolve any complaint over the phone. You may also send your complaint in writing to the following:

WellCare PDP
Grievance Department
PO Box 31384
Tampa, FL  33631-3384

You can also fax a grievance to: 1-866-388-1769.

We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-888-547-5252 (TTY/TTD users call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern. 

If you would like to obtain an aggregate number of grievances, appeals and exceptions file, please contact Customer Service at 1-888-547-5252 (TTY/TDD users call: 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern. 

Tier Cost Sharing

Tier Cost sharing is a term that means there is cost sharing for drugs that are classified under tier levels. Each level has co-payment amounts that the member is responsible to pay. The WellCare formulary has five tiers—preferred generic, non-preferred generic, preferred brand, non-preferred brand, and specialty.

If you have any questions about coverage determinations, exception requests, appeals or grievances, please contact Customer Service at 1-888-547-5252 (TTD/TTY users, call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern.